International Journal of Health Care Quality Assurance

Patient choice of a hospital: implications for health policy and management

Ali Mohammad Mosadeghrad
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Ali Mohammad Mosadeghrad , (2014),"Patient choice of a hospital: implications for health policy and management",
International Journal of Health Care Quality Assurance, Vol. 27 Iss 2 pp. 152 - 164
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CGIJ-05-2012-0016
Yogesh P. Pai, Satyanarayana T. Chary, (2013),"Dimensions of hospital service quality: a critical review: Perspective of
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IJHCQA
27,2 Patient choice of a hospital:
implications for health policy and
management
152
Ali Mohammad Mosadeghrad
British Institute of Technology and E-Commerce, London, UK
Received 18 August 2012
Revised 21 November 2012
Accepted 25 March 2013
Abstract
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Purpose – The purpose of this study was to identify the most important influencing factors in
choosing a hospital by a patient.
Design/methodology/approach – This study involved a mixed research design. Focus groups and
in-depth individual interviews were conducted with patients to explore reasons for choosing a hospital.
In addition, this study involved survey-based research on the patient choice.
Findings – Type of the hospital, type of the service, word of mouth, cost of services, the health
insurance programme, location, physical environment, facilities, providers’ expertise and interpersonal
behaviour, and reputation of the hospital influenced patients’ choice of a hospital. Doctor
recommendations and health insurance programme were the main reasons for choosing a hospital for
inpatients and outpatients respectively.
Practical implications – Identifying and understanding key factors that influence a patient choice
of a healthcare setting helps managers and policy makers invest their resources in those critical areas
and improve those aspects of their services to attract more patients.
Originality/value – This article contributes to healthcare theory and practice by developing a
conceptual framework for understanding the factors that influence a patient choice of a healthcare
setting.
Keywords Patient perception, Customer
Paper type Research paper

Introduction
The Iranian healthcare system is characterised by a strong public sector component.
Public healthcare services are complemented by the private sector (i.e. private hospitals
and independent medical practitioners’ clinics). The Ministry of Health and Medical
Education (MOHME) provides 70.9 per cent of the healthcare services. Private
institutions provide 18.8 per cent of the services. The social security organisation is
responsible for 2.7 per cent of the services; charity institutions 1.9 per cent and other
organisations cover 5.7 per cent (Mehrabi et al., 2008). The healthcare system is
structured into three levels:
(1) Free of charge primary healthcare (PHC) services delivered by MOHME. This
International Journal of Health Care
Quality Assurance
level includes rural health houses, rural health centres, urban health posts and
Vol. 27 No. 2, 2014 urban health centres.
pp. 152-164
q Emerald Group Publishing Limited (2) District health networks and district hospitals.
0952-6862
DOI 10.1108/IJHCQA-11-2012-0119 (3) Provincial health centres and specialty hospitals (Mosadeghrad, 2003).
 At the national level, MOHME is responsible for policy making, planning, financing, Patient choice of
directing and controlling public healthcare services. The Ministry of Health and a hospital
Medical Education is also responsible for regulating, monitoring and accrediting the
private health sector. At the provincial level, the medical sciences universities are
responsible for providing healthcare services. At the urban and rural levels, a district
health network comprises urban and rural health centres, health posts and health
houses, which are charged with the responsibility (WHO, 2006). 153
There are also other organisations that play a leading role in policymaking, tariff
setting and service delivery such as Social Security Organisation (SSO) and Medical
Services Insurance Organisation (MSIO). Charity healthcare institutions, which focus
mainly on providing outpatient services and several healthcare institutions affiliated
with the ministries of welfare, oil and defence, which provide secondary and tertiary
care, mainly to their employees, further complicate the system and perhaps make it less
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efficient (WHO, 2010).

Tax, health insurance programmes and out-of-pocket payment are sources of
financing healthcare services in Iran (WHO, 2006). All formal workers and their
dependents are insured by SSO. They pay nothing for services provided in SSO
facilities. However, they have to pay 10 and 25 per cent for inpatient and outpatient
care provided in non-SSO facilities respectively. Military force members and their
dependents are covered through the Armed Forces Medical Service Organisation. The
remainder is eligible to enrol in MSIO, which has four funds covering government
employees, rural households, self-employed and “others” (e.g. students). The MSIO is
compulsory for the government employees and voluntary for the other groups.
Additionally, The Imam Khomeini Relief Foundation finances healthcare services for
the poor. Private insurance generally is supplemental to these public programmes.
Patients are free to choose healthcare settings or providers. There is no referral
system from the primary healthcare to secondary and tertiary levels. Therefore, there
is a tendency in patient choice from a generalist physician (GP) to a specialist physician
(medical consultant). Many patients prefer to bypass GPs and receive healthcare
services from specialist physicians (LeBaron and Schultz, 2005). Nowadays, a GP has
fewer patients than a medical consultant. Low medical tariff makes it easier for
patients to see a medical specialist. The disparity between GP fees and a medical
consultant is not much. Therefore, patients prefer to be seen by a medical specialist.
Medical insurance companies make it even more affordable for patients to see a
medical specialist. Furthermore, the doctor visit fee is the same for simple or more
complicated cases. It leads to competition between the GP and the specialist, with the
latter perceived as holding the upper hand. Hence, there is no motivation for medical
consultants to convince patients to be seen first by a GP. They may prefer to see more
simple cases as it takes less time and they can see more patients and have more income.
Moreover, patients’ lack of trust in medical doctors and unfamiliarity with medical
practices increases uncertainty and leads to repeated medical visits. Consequently,
demand for specialised healthcare services is increasing, which is beyond the resources
of healthcare organisations or even payers. Employees, particularly clinical staff are
overworked. Providers have to limit their flexibility and adaptability to the patients’
individual needs owing to staff shortages and time constraints. The increased demand
for medical services may force physicians to transfer patients to paramedical
departments rather than properly examining patients to achieve an accurate diagnosis.
 IJHCQA This results in patients’ complaints and dissatisfaction. Unnecessary patient referral to
27,2 paramedical departments increases paramedics’ work burden. This in turn increases
their job stress, resource utilisation and probability of errors.
The Ministry of Health has therefore initiated the family physician programme for
urban areas in 2012 to enhance the referral system from primary to secondary and
tertiary healthcare service delivery. Each family physician covers around 3,000 to 3,500
154 people. Patients have to be seen first by a GP and, then be referred to a hospital or a
medical specialist if it is necessary. The programme aims to improve the accessibility
of healthcare services and to reduce unnecessary patient referrals to specialised
hospitals. Although the government is responsible for providing healthcare services to
patients, it is also responsible for giving them a provider choice at referral by the GP.
Hence, it is necessary to understand factors that influence a patient choice of a
healthcare setting.
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Patient choice reduces inequities in access to care, promotes competition among

health care providers, increases providers’ responsiveness to the patients’ needs,
increases the efficiency of healthcare organisations and enhances the quality of the
service provided.

Literature review
Patient choice is a complex process. Factors relating to both health care providers
(i.e. ownership, size, capacity, service type and number, service availability and
accessibility, accreditation, location, performance and reputation) and receivers
(i.e. gender, age, race, medical condition, payment sources and knowledge) affect
patient choice of a healthcare-setting (Adams and Wright, 1991; Chernew et al., 1998;
Exworthy and Peckham, 2006; Luft et al., 1990; Phibbs et al., 1993; Roh et al., 2008; Tai
et al., 2004). These factors can be discussed as the ten P’s of healthcare services
marketing:
(1) Product. The type of healthcare service is an important factor for choosing a
healthcare setting. Hence, the availability of healthcare service plays a critical
role in patient choice.
(2) Place. The availability of healthcare service is a necessity but it is not enough.
Healthcare services should also be accessible to clients any time they need them
if they are to be considered useful. Hospital distance from the patient’s
residential location is an important determinant of hospital choice. The
geographic distance is a limiting factor in hospital choice especially for older
patients (Adams and Wright, 1991; Luft et al., 1990).
(3) Price. Affordability is a key access component especially when the cost of
service is high and the patient has no insurance programme. If a patient cannot
afford to visit a doctor or pay for clinical tests, then there is inadequate access to
healthcare.
(4) Physical environment. Although a hospital is a place for treating diseases, there
is always a chance of getting contaminated with diseases. Patients prefer a
clean and homelike environment. Fears of hospital acquired infections make
patients consider physical cleanliness and hygiene in their healthcare setting
choice. A clean hospital assures patients that they are safe. Other tangible
quality aspects such as amenities and tasty food are also important for patients.
 Hospital size (total beds) was found to positively and significantly affect Patient choice of
patients’ hospital choice. Patients are more likely to choose hospitals with a a hospital
larger number of beds (Adams and Wright, 1991; Goldsteen et al., 1994).
(5) People. Patients desire for technically knowledgeable, skilful and experienced
providers capable of accurate diagnoses and effective treatment. Competent
healthcare providers seemed to be an important quality indicator for patients.
Many patients rely on interpersonal relations attributes such as effective 155
listening, trust, respect, confidentiality, courtesy, sympathy, understanding,
responsiveness, helpfulness, compassion and effective communication between
providers and clients to evaluate healthcare quality because they lack sufficient
technical knowledge. Clients like providers not only to do their technical jobs
but also to be caring, polite, courteous and friendly, to show respect, empathy,
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sensitivity and kindness, and to express compassion and sympathy for the
patient. Patients expect their caregivers to be more responsible and accountable
and provide prompt service. It is important for patients to get emotional support
from providers to help reduce their vulnerability and anxiety.
(6) Processes. Process includes all those healthcare activities in a setting for a
patient to help him or her retrieve his/her health. It involves policies and
procedures for delivery healthcare services in a hospital.
(7) Package. Package deals with the health service comprehensiveness and
completeness. Patients prefer hospitals that offer several healthcare services
(Goldsteen et al., 1994; Phibbs et al., 1993). Patients are willing to travel farther
to reach hospitals that provide a wider variety of healthcare services.
(8) Performance. Performance covers mainly the healthcare clinical effectiveness.
Patients prefer healthcare settings with lower morbidity and mortality rates.
(9) Position. Position (image) accounts for all the previous P’s to ensure that each
patient has a good experience with the healthcare setting. All these factors
shape the patient’s perceptions. The hospital image in the eye of a patient is
based on his or her subjective assessment of clinical outcomes of the hospital
and its clean environment and facilities for patients and visitors (Miller and
May, 2006).
(10) Promotion. Patients seek also recommendations of healthcare professionals,
family relatives and friends to find an appropriate healthcare setting to receive
healthcare services. Television, newspapers and magazines can also promote
healthcare settings. The promotion factor is closely related to the healthcare
setting’s position in the society.

Many studies have been done on patient choice internationally, but limited studies
were done in Iran. Identifying factors that influence patient’s choice of a healthcare
setting helps policy makers and managers to understand what their potential patients
view as important to their healthcare.

Methodology
Purpose and objectives
This study aims to explore the reasons why patients choose a healthcare setting.
 IJHCQA Method
27,2 A qualitative approach is an appropriate method for such an exploratory study. Therefore,
focus group discussions and individual interviews were used for data collection.
Additionally, a questionnaire survey was conducted to supplement the qualitative data.

Settings and participants

156 Hospital care in Iran is provided by a network of regional hospitals located in the main
cities. This includes the government financed Ministry of Health (MOH) hospitals, the
Social Security Organisation affiliated (SSO) hospitals and private hospitals. The study
was carried out at in eight hospitals: four MOH (three teaching and one non-teaching),
two SSO and two private hospitals to represent the three dominant hospital care
systems in Iran.
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Ethical consideration
Ethical approval was gained from Isfahan Medical University’s Research Ethics
Committee. The main ethical issues involved in this study were respondents’ rights to
self-determination, anonymity and confidentiality. Respondents were given full
information on the study’s nature. Respondents were assured of their right to withdraw
at any time.

Data collection
Interviews with in-patients were conducted by the researcher in a private room off the
main ward. Some inpatients were interviewed in the patients’ rooms when the interview
room was unavailable. Interviews with outpatients were conducted in the outpatient
department after they received services. Patients were asked to articulate factors that
influenced their decision to choose a hospital. The interviews were recorded using a
digital voice recorder with the participants’ permission to facilitate analysis. In
quantitative study, patients were asked to choose their reasons for choosing the hospital
from a list of responses that were elicited from the qualitative study.

Data analysis
The author himself transcribed the digital files. Confidentiality was assured and
anonymity protected by alphabetical and numerical codes on voice records and reports.
Both qualitative and quantitative analyses were used in this study. Content analysis
explored the reasons for choosing a hospital. Open, axial and selective coding (Strauss
and Corbin, 1998) were applied to the data to detect and code reasons for choosing a
hospital, organise them into logical and meaningful categories, make connections
between and among categories, explain the link between categories and develop a
theory from the relationships found among the categories. NVivo software (version 7)
was used for qualitative data analysis and retrieval. The SPSS software (version 11.5)
was used for quantitative data to provide descriptive statistics such as frequency, and
percentage.

Evaluating research quality

The researcher has not allowed personal values to influence research conduct and
findings. Member checks (respondent validation) were done in face-to-face discussions
with a participant subgroup to verify and validate the findings.
 Results Patient choice of
Participants characteristics a hospital
A total of 320 patients participated in the qualitative study. In each hospital, four focus
group discussion meetings were conducted with inpatients who were admitted in the
hospital for more than two days. Thirty-two focus groups were conducted with 256
inpatients (eight inpatients in each group). Moreover, a purposive sample of eight
outpatients in each hospital was invited to participate in individual interviews 157
(n ¼ 64). Inclusion criteria were: Persian speaking; 15 years or older; not suffering from
severe mental or cognitive disorders; willing to participate; and communicable.
In addition, a survey was administered on 1,303 patients (747 inpatients and 556
outpatients) to get an understanding of the factors affecting patient choice. Table I
shows the main demographic characteristics of the interviewees and the respondents.
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Factors affecting patient choice (qualitative study)

Eleven factors were found to be important for patients when they selected a hospital:
service type, hospital (teaching/non-teaching), word of mouth (recommendation), cost,
patient’s medical insurance programme, location (easy access), physical environment,
facilities, providers’ expertise (skills and experience), providers’ interpersonal
behaviour (courtesy), and hospital reputation (image).

Qualitative study Quantitative study

Demographic variables IP OP IP OP

Gender
Male 50 48.4 48.8 41.5
Female 50 51.6 51.2 58.5
Marital status
Single 21.4 10.9 19.4 37.7
Married 78.6 89.1 80.6 62.3
Age
Less than 20 years 9.4 4.7 9.6 22.2
20 to 29 years 19.9 31.3 21.7 32.4
30 to 39 years 25.4 29.7 19.9 17.8
40 to 49 years 23.8 18.8 16.2 15.0
50 years or older 21.5 15.6 32.6 12.6
Education
Illiterate 12.5 3.1 19.3 5.6
Under diploma 45.7 43.7 41.7 31.6
Diploma 30.0 31.3 24.2 35.8
Post diploma 3.9 6.3 6.3 9.8
Bachelor of Science 6.3 12.5 7.6 16.6
Master of Science 1.6 – 0.6 0.6
PhD – 3.1 0.3 – Table I.
Participants demographic
Notes: IP: Inpatient; OP: Outpatient characteristics
 IJHCQA Service type
27,2 Service availability is an important factor for choosing a healthcare setting particularly
for patients looking for scarce services: “This is the only public hospital in the city I
could come to do my surgery.” (IPG7) “I went to a doctor’s clinic. He diagnosed my
disease as gastro carcinoma and told me to come to this hospital” (IPG30).

158 Hospital type

Medical and nursing trainees in teaching hospitals are involved in patient treatment.
Some patients prefer not to go to these hospitals, as they cannot trust the staff. “I do not
go to hospital X as there are a lot of [medical] students there” (IPG5).

Recommendations
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Most patients are not well informed about their diseases and have to follow their
doctor’s recommendation: “My doctor is practicing in this hospital. That is why I came
here. If he worked in a private hospital, I would go there” (IPG2). “I wish I could go to
hospital ‘D’, where I am working. Unfortunately he [the doctor] does not practice there”
(IPG29). Patients also consider their friends or family relatives’ recommendations, if
they do not have previous experience of admission to a specific hospital: “I consult with
my friends to choose an appropriate physician” (OP10). “My sister in law
recommended this hospital. She had her delivery here and was satisfied” (IPG17).
Patients prefer to go to a hospital where a friend or family member works and could be
helpful to them: “My cousin works in this hospital. She introduced me to her colleagues
and asked them to look after me” (IPG6).

Services cost
For people with low-incomes, service cost is a key factor in choosing a particular
healthcare setting: “Hysterectomy would cost me about 7 million RLS in a private
hospital. It would be 400,000 RLS here [public hospital]” (IPG10). “The tariff for a
[medical] specialist visit is 9,000 RLS here [public hospital], while outside [private
clinic] it would be 50,000 RLS” (OP8).

Patient’s medical insurance programme

Patients’ insurance programme is another factor that directs them to a specific
healthcare setting: “I chose here because my company has a contract with this
hospital” (IPG1). “I came to this hospital because of my [health] insurance
[programme]” (IPG21).

Location (access)
Location is an important reason for choosing a hospital. Patients prefer to go to the
nearest healthcare setting to receive services, if they know that service quality is
acceptable. “I chose this hospital] because it is close to my home” (IPG18). “It is more
convenient for me to come to this hospital. I just get on a bus and then get off in front of
the hospital” (OP45). If service quality is not good, access cannot be an important factor
in patient choice, “I asked the doctor to refer me to hospital X which is close to my
home. I was there for four days, care was not good, so I decided to come to this hospital
[another public hospital]” (IPG2). Patients consider their relatives’ comfort by looking
for the nearest hospital as well: “I wish I was admitted in a hospital in my city. It could
 be more convenient for my family. They have to come a long way every day to see me Patient choice of
here. There is no hospital in my city to cure me” (IPG31). a hospital
Facilities
Facilities and amenities in healthcare organisations also influence patient choice: “I
chose this hospital, because it has more facilities for patients and visitors” (IPG11). “It
is great that I have a private room. I am very comfortable here” (IPG17). “I wish patient 159
rooms looked like hotel rooms and had TV, fridge, etc.” (IPG1).

Physical environment
The healthcare environment’s appearance – design, cleanliness and tidiness – is an
influential factor in patients’ choice. “I could get the services from hospital ‘X’
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completely free of charge [because of her insurance programme], but I decided to come
to this hospital [private hospital]. It is very clean. They clean the room three to four
times a day and change the bed sheets, blanket and clothes every day” (IPG7). “I have
to come to this hospital for a blood transfusion regularly. I worry about the diseases,
which can be transmitted through blood” (OP57).

Providers’ skills and experience

Patients expressed a desire for technically competent and skilful providers who
diagnose accurately and treat patients effectively. “The doctor’s diagnosis in hospital
‘X’ was wrong. I had internal bleeding and he gave me anti-acids. I then came to this
hospital. The doctor sent me immediately to the operation theatre. Now, I feel better”
(IPG13). As patients are looking for effective treatment, they prefer to visit a competent
doctor who helps them to recover completely. “I’ve seen many doctors for my breathing
problem. I used to use an inhaler and take medicines. A doctor should resolve the
problem permanently, not just prescribing the medicines. This woman [pointing at the
physician’s office] advised me to do an operation. I am very satisfied, I can breathe
easily” (OP10).

Providers’ interpersonal behaviour

Doctors’ and nurses’ attitudes are important for patients. “The nurses are shouting at
us. Their attitude is so bad. If I knew this, I never would have come here” (IPG13). “I
went to Tehran for my disease. Doctors and nurses were very kind there to me. I did
not like to come back home [Isfahan]” (IPG9).

Hospital/provider reputation
Patients distinguish between different hospitals using their reputation. Clinical
effectiveness, hospital type, cleanness, staff personal relations and word of mouth
contribute to the hospital’s overall image. “If someone tells me that there is just one
doctor who can cure me and he/she is just working in hospital ‘X’, I will not go there. I
have done a surgery on my finger there. Now, I cannot move it properly. My mother
was also once admitted there. The doctor said that her foot should be amputated. We
went to another hospital and she got better. Hospital ‘X’ is an abattoir” (IPG5). “I was
told in hospital ‘X’ that my hand should be cut off. Thus, I decided to come to this
hospital” (IPG8).
 IJHCQA Patients’ demographic variables
27,2 There are other mediating factors that influence patient choice such as patient’s
education and socioeconomic class. Educated patients usually have more information
about their disease, so are more obsessed about their choice. “I am a dentist. I prefer to
be seen by an experienced and knowledgeable doctor” (OP10). Receiving services from
a private hospital is a prestigious ambition for some patients especially in society’s
160 higher socio-economic levels. It could be because of service cost, which is not easily
affordable to the others or receiving individualised services: “The prestige of the
hospital is important for me. I prefer to go to a private one” (OP52).

Factors affecting patient choice (quantitative study)

The findings of the questionnaire survey revealed that recommendations from doctors
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and the providers’ expertise were the main reasons for choosing a hospital by
inpatients and outpatients respectively (Table II). These quantitative findings support
the qualitative results.
Service cost was the main reason for choosing public and semi-public hospitals.
Over 71 per cent of the public hospital patients reported a monthly income lower than
US$200, indicating that public hospitals are mainly used by people with low income
who have no other choice. The Social Security Organisation provides healthcare
services in its affiliated hospitals for its insured clients, free of charge. Therefore, for
people for whom service cost is a concern, the social security hospital is the first choice.
Approximately 36 per cent and 53 per cent of inpatients and outpatients respectively
chose the social security hospital because of their insurance programme.
Patients believe that service quality in private is better than public hospitals.
However, a several patients suggested that private hospital services are too expensive
for them. More than three quarters of inpatients in private hospitals asserted doctors’
recommendations as their reason for choosing the hospital. Insurance coverage was the
main reason for outpatients’ private hospital choice. Insurance shields them from price
differences among public and private hospitals. Reasons for people going to a private
hospital having previously received services from a public hospital include shorter

Semi
Public public Private All
Reasons for choosing the hospital IP OP IP OP IP OP IP OP

Easy access (location) 6.8 16.0 8.4 20.7 3.0 25.6 5.9 19.2
Friends or family members recommendation 15.9 24.5 7.6 9.1 17.7 17.8 15.1 19.6
Doctor recommendation 46.2 19.3 24.4 10.7 78.1 27.9 52.6 19.4
Services cost 42.0 19.0 44.8 22.3 28.0 28.2 29.7 21.2
Insurance programme 14.6 19.9 36.1 52.9 4.3 34.1 14.9 30.4
Physical environment 7.1 1.3 4.2 3.3 4.6 7.8 5.5 2.8
Hospital facilities 10.6 4.9 16.0 7.4 14.7 30.3 12.7 9.5
Hospital reputation 9.8 9.8 6.7 3.3 12.9 12.4 10.3 9.0
Providers’ skills and experience 40.4 42.2 40.3 38.0 33.6 46.5 38.2 41.8
Providers’ interpersonal behaviour 14.9 10.8 13.4 5.8 11.2 38.0 13.5 13.8
Table II. No choice (emergency) 32.3 7.8 21.0 5.0 3.0 3.1 21.4 6.1
Reasons for choosing the
hospital Notes: IP: Inpatient; OP: Outpatient
 waiting time, receiving care from doctors not medical students, clean environment, Patient choice of
more facilities and staff courtesy. a hospital
Stepwise regression analysis revealed that cost of services, access, patient health
status, and providers’ expertise were the main reasons for choosing a hospital. A
statistical significant association was seen between patients’ hospital choice and their
education ( p , 0.001), age ( p ¼ 0.007) and job ( p ¼ 0.040).
161
Discussion
Figure 1 shows the patient choice process. Choosing a healthcare setting reflects the
preferences of a patient, his or her family and the physician, all of which are potentially
restricted by patient’s insurance programme.
Disease is the initial factor affecting a patient’s choice. A patient considers a several
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healthcare settings that provide the required service. Choosing one, he/she relies on
either his/her previous experience or people’s recommendations (i.e. physician, friends
and family relatives) along with access, cost and service quality. If a patient can afford
the costs, high quality services would be the first choice. The patient chooses the
nearest one if they are providing the same quality. However, dealing with human life
and death makes it more complicated. Patients may be willing to travel or accept
higher costs if they think that services are effective. This finding is consistent with
other studies that patients are more likely to bypass their local hospital and travel to
other hospitals where service quality is better (Roh and Lee, 2006; Varkevisser and van
der Geest, 2007).
Illness severity is the strongest determinant of healthcare setting choice. Patients do
not consider access and cost and sometimes quality if they are in an emergency for
which any delay would result in serious problems or even death. Hence, an experienced
provider (in this case a physician) plays the determinant role in a patient’s choice. This
physician may work – in a public or private, high or poor quality or close or far
hospital from a patient’s house. Patients with more severe illnesses tended to choose
larger hospitals more often than patients with less severe illnesses (Adams and Wright,
1991; Bronstein and Morrisey, 1991; Phibbs et al., 1993). They prefer to go to a hospital
with more specialized services for high-risk patients.

Figure 1.
The patient choice process
 IJHCQA This study revealed that service quality is an important factor for choosing a hospital
27,2 from a patient perspective. This finding is similar to the findings of other studies
(Coulter et al., 2004; Habtom and Ruys, 2007; Taylor et al., 2004). Quality is a subjective,
complex and multi-dimensional concept in healthcare. Patients place more emphasis on
effective services, ready access to experienced and helpful providers, clean and safe
environment, and facilities and amenities. For them, the most important attributes of
162 quality healthcare are having their medical problem resolved, having skilled,
competent, supportive and caring providers who are concerned about them, listen to
them, protect their privacy, involve them and their families in the decisions about their
treatment, and give them equal care.
Nevertheless, many healthcare customers are not well informed about issues
related to their health due to the complexity of medical knowledge. They have to
trust their doctors and ask them to make decisions on their behalf. The doctor acts
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as both the “agent” and the “healthcare provider” for the patient. As a physician’s
role is critical in recommending a hospital to a patient, managers compete to recruit
well-known doctors (supplier-induced demand). The physician’s power to influence
patient choice of a hospital diminishes the patient’s ability to choose independently
and freely.
Patients should have the right to choose their healthcare providers and highlight
their preferences. They should be encouraged to use quality as the major factor in
choosing a hospital. However, they rarely use objective performance measures for
choosing a hospital. Patients should have appropriate and relevant information on the
quality of hospital services to inform their decision. The collaboration between a
physician and a patient helps the patient make choices independently based on the
physician’s experience and the medical facts (Quill and Brody, 1996). Patient choice
should be supported with information. The Ministry of Health of Iran should initiate
systems to provide patients with information about the quality of hospital services.
The system should be designed in a way to make it easier for patients to search and
compare these objective performance measures.
Patient choice can act as a driver for improving service quality through promoting
competition between healthcare providers and encouraging patient-centred services.
Providers have to improve quality to attract patients. Otherwise, they have to quit the
market. Patient choice encourages healthcare providers to be more responsive to
patients’ preferences. However, there are factors that limit patient choice. These include
lack of healthcare resources, uneven resource distribution, lack of information on
provider outcomes and providers’ resistance. Iranian healthcare policy makers need to
be aware of, and address these barriers if the patient choice and the family physician
programmes are to have positive impacts on accessibility, quality and efficiency of
healthcare services.

Conclusion and implications for policy makers

This study set out to explore reasons for patients’ healthcare setting choice. The
findings have implications for healthcare policy makers and provide recommendations
for developing further the family medicine programme in Iran. “Patient-led” and
“evidence-based” approaches to healthcare should be emphasised. Hence, healthcare
organisations should make their services more responsive to their clients’ needs.
 Patient choice has to be emphasised across the healthcare system. Patients should be Patient choice of
offered a choice over when, where and by whom they should be treated. a hospital
Necessary and appropriate information should be offered to patients to make
decision about hospital choice. Information should be provided on service quality,
mortality and morbidity rates, operation success rates, hospital cleanness and
facilities. As a result, the patient can make an informed decision. Proving valid and
reliable information on appropriate self-care also reduce primary care consultations for 163
minor ailments. Additionally, patients should be able to raise their voices, rate and
comment on healthcare services received.

Limitations and implications for further research

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The individual interviews and focus groups were useful in identifying factors that
influence a patient’s hospital choice. Additionally, the quantitative surveys were used
to measure the frequency and distribution of patients’ reasons for choosing a hospital.
Quantitative and qualitative studies complement and strengthen each other in this
research. Using mixed methods provided support and cross-validation, so that findings
were likely to be more valid than using a singular method. Despite the study’s
contributions, the results need to be interpreted with caution owing to some
methodological limitations. This study was limited to particular participants in Iranian
hospitals. Thus, the results may not be valid in other countries. An additional sample
with participants from other countries would give a clearer view of factors that
influence patient’s healthcare setting choice.

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Corresponding author
Ali Mohammad Mosadeghrad can be contacted at: mosadeghrad@gmail.com

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